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Identifying Coronary Artery Calcification on Non-gated Computed Tomography Scans
Published on: August 28, 2018
Hypertension attenuates the prognostic value of coronary artery calcification scoring in low-risk patients
Edd Maclean1, Joban Sehmi2, Gajen Kanaganayagam3
1William Harvey Research Institute, Queen Mary University of London, London, UK.
Insights
Coronary artery calcium scoring (CACS) underestimates cardiovascular risk in hypertensive patients, while CT coronary angiography (CTCA) provides crucial prognostic information, especially for non-calcified plaque.
Area of Science:
- Cardiovascular imaging and diagnostics
- Risk stratification in cardiology
- Preventive cardiology
Background:
- Assessing cardiovascular risk in patients with suspected ischemic symptoms is crucial for guiding treatment.
- Coronary artery calcium scoring (CACS) and CT coronary angiography (CTCA) are non-invasive imaging modalities used for this purpose.
- The influence of patient risk factor profiles on the prognostic accuracy of these imaging techniques requires further investigation.
Purpose of the Study:
- To investigate how patient risk factor profiles affect the prognostic value of CACS and CTCA in outpatients with suspected ischemic symptoms.
- To determine if CTCA offers additive prognostic information beyond CACS, particularly in specific patient subgroups.
- To evaluate the performance of CACS, including a threshold of >400, in predicting major adverse cardiovascular events (MACE) across different risk profiles.
Main Methods:
- A cohort of 772 consecutive outpatients with suspected ischemic symptoms underwent both CACS and CTCA.
- Patients with significant coronary artery lesions requiring revascularization within 60 days (n=52) were excluded, leaving 720 patients for follow-up.
- Follow-up for major adverse cardiovascular events (MACE) was conducted for an average of 38.1 months.
Main Results:
- A total of 27 patients (3.8%) experienced MACE after a median follow-up of 38.1 months.
- Hypertension was a strong predictor of adverse outcomes (HR 6.5) and was associated with a higher prevalence of non-calcified plaque.
- While severe stenosis on CTCA predicted MACE in both normotensive and hypertensive patients, CACS > 400 predicted MACE only in normotensive individuals, and a zero calcium score did not rule out MACE, especially in hypertensive patients.
Conclusions:
- CTCA provides significant additive prognostic information compared to CACS in low-risk patients with stable cardiovascular symptoms.
- CACS, including a threshold of >400, may underestimate cardiovascular risk in hypertensive patients due to a higher prevalence of non-calcified plaque.
- Risk stratification using coronary imaging should consider the patient's overall risk factor profile, particularly hypertension.
Objectives:
In outpatients with suspected ischaemic symptoms, we investigated the impact of risk factor profile on the prognostic value of coronary artery calcium scoring (CACS) and CT coronary angiography (CTCA).
Methods:
772 consecutive patients underwent CACS and CTCA; 52 patients (6.7%) with significant coronary artery lesions underwent revascularisation within 60 days and were excluded. 720 remaining patients were followed up for 38.1±17.4 months.
Results:
Late presentation (after 60 days) major adverse cardiovascular events (MACEs) were recorded in 27 patients (3.8%). Hypertension was strongly associated with adverse outcomes (unadjusted HR 6.5 (2.9 to 14), p<0.001), and hypertensive patients had double the prevalence of non-calcified plaque versus normotensive individuals (30.2% vs 14.3%, p<0.001). Adjusting for confounders, severe stenosis at CTCA was predictive of MACE for normotensive and hypertensive patients (HR 9.6 (2.8 to 43.1), p<0.001, and HR 6.2 (2.4 to 16.1), p<0.001, respectively). CACS alone was not predictive of MACE throughout the cohort (HR 1.001 (0.9997 to 1.001), p=0.36) and when adjusting for confounders, a cut-off of CACS>400 predicted MACE in normotensive individuals (HR 10.6 (2.41 to 49.3), p<0.001) but not in hypertensive individuals (HR 1.3 (0.5 to 3.6), p=0.56). Zero calcium score did not mitigate the risk of MACE (HR 0.84 (0.39 to 1.8), p=0.65) and 13/27 patients (48.1%) who suffered MACE had a 0 calcium score; all had hypertension.
Conclusions:
In low-risk patients with stable cardiovascular symptoms, CTCA provides important additive prognostic information over CACS, and CACS (including CACS>400) underestimated cardiovascular risk in patients with hypertension. This may relate to the increased prevalence of non-calcified plaque in these individuals.
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